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32A-260 (2) t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations , 600 Washington Street Boston, MA 02111 u www.nzass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): )�,r( rj I V1C°t'Vj'i l'� Address: - Vti-0 City/State/Zip: L ',' k 13 :3 Phone#: I�rC��15 �;Tr Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction -__ 2, I am a sole proprietor or_partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance.$- required.] 5. ❑ We are a corporation and its MwFectrical repairs or additions �.❑ I am a homeowner doing all work officers have exercised their I L Plumbing repairs or additions myself.m se o workers'comp. right of exemption per MGL Y [N p 12.7 Roof repairs insurance required.]t c. 152, §1(4),and we have no p,<J re employees. [No workers' 13.�Other �V comp.,insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am are employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self=-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be.advised that a copy of this statement may be forwarded to the Office of Investigations of theADIA for insurance coverage verification. I do hereby fe rt' rider thepains andpenalties ofperjury that the information provided above is true and correct. (z nature: 2 Date: 1 Phone#: l 3 �) r� ' (e 4" Official use onl)l. Do not write in this area, to be completed by city or town official --— —City or Town: - Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-,STRUCTURAL PEER REVIEW(780 CMR:1.10.11) Independent Structural Engineering Structural Peer Review Required Yes No SECTION 11 OWNER.AUTHORIZATION-TO BE COMPLETED.WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING:PERMIT as Owner of the subject property hereby authorize r\j-I S "Tr)ovp7s..G __=to act on my behalf,1 II matters relative t work authorized by this building permit application. Signature of Owner Date as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains.and penalties-ofperlury_. .. Print Name S Signature of O` t Date SECTION 12-CONSTRUCTION:SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:? (-. w .!..__X`Q �!1 ., .__.,, ... _ ., .._ w_.. �. _ �1�.­' 1 ... License Number ddress Expiralion lbate Sign a _ ." Telephone -3: INSURANCE AFFIDAVIMc 152;§25C(6))SECTION Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes 4&1 No 0 Versionl.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN'AND CONSTRUCTION.SERVICES-FOR BUILDINGS-AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL.PURSUANT TO 780 CMRJ16(CONTAINING MORE THAN 35,000 C.F.OF EN LO$E©SPACE) 9.1 Registered Architect: Not Applicab Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility s ___....... .....-.._ Address Registration Number Signature Telephone Expiration Date 1 Name Area of Responsibility __._...._.._....__._ Address Registration Number Signature Telephone Expiration Date t Name Area of Responsibility Address Registration Number __...._.__......______..._................__.....__._...__........................... ..__._.......__. Signature Telephone Expiration Date ..........._....._......_....._....._....___.. - _.._.. _._..._ _ _ �. _. .. �., w, »r..__ _ f ..__ .._...._.._ _. __._M_.._....._._ _.....,,....._...._....... ..._.... i ........... _.-__.._.,_ ....................,_..... . . .... ......_ Name Area of Responsibility t I 4 Address Registration Number i Signature Telephone I Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Responsible In Charge of Construction ._ _ » _ r Address 13 V,., �_ Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 8_ .NORTHAMPTON,ZONING.. Existing Proposed Required by honing This column t6 5e filled in by Building Department Lot Size Frontagez.._M.......... . ........ : .. >w _ _ _. . _.:_.... __ _.__._.,. .._, Setbacks Front Side L: ? R;L_._ .._. L:L _l R:':..w..._.J Rear Building Height OX ;._.._.._._., _ ; ,....... , Bldg. Square Footage """'€ /o Open Space Footage % Lot area minus bldg&paved # t 4 parking) #of Parking Spaces _._..__. ..._... ... ..._... ...__..._ ._ _.__.,._ ...____... ___._,..._ __..... ....._..... ,. .. Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES 0 AF.YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 t YES ._. w _ .__._. __...._..., IF YES: enter Book '' Page= and/or Document# B. Does the site contain a brook, body of water or wetlands? NO1 DONT KNOW YES Yoe 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: _._.�..___._......�.�.._..._._..�. _.__._.,_ __m....__..,___,"._.. ........_.. _..._.. _...........__.._..........................................._........_._....._........._... ......._......_.._...................._....___........._.._._....._._.................-.....;: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version 1.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION:SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE- Interior Alterations ❑ Existing.Wall Signs ❑ Demolition❑ Repairs Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑ Brief Description Enter a brief description here. . Of Proposed Work: -1- x' 1, 1 r' SECTION 5-USE GROUP AND:CONSTRUCTION TXP.E USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 213 ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ __: = °' = 3A ❑ Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑' S Storage ❑ S-1 ❑ S-2 ❑ 5B U Utility ❑ Specify: M Mixed Use ❑ Specify: i S Special Use ❑ Specify: �..-.. ....�...-.,�� .�......�..w.._._.. ._._..��...�.._...................__W......_.._..�...... COMPLETETHIS SECTION.IF.EXISTING::BUILDING UNDERGOING RENOVATIO..NS,ADDI-TIONSAND/OR.CHANGE IN USE Existing Use Group. _ _._ Proposed Use Group. Existing Hazard Index 780 CMR 34)::'----- Proposed Hazard Index 780 CMR 34) SECTION.6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE'USE Floor Area per Floor(so 1 9t r_ _ _ 2nd t 2nd � . _ . ................_............, . ........ rdE..._...».»...........»....,... tom...-... ................... ...................-.....� 3`d 3 4ch 4th Total Area(so Total Proposed New Construction �9_ _ _......_ M _ Total Height(ft) ---- --- Total Height ft _ 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood_Zone,Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone'-,".,,- ' Outside Flood Zone❑ Municipal 0 On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 Departme #usefionlX 0 V i E City of Northampton Statdt of Pe�� "� • � i i.g F�x+;`�"'� E.y�� � yea Building Department Curb Pe Cut/Drtrreway` " q ���� 212 Main Street Sewer/Septi �lvatlafr�trty� �7 t Room 100 WaterMCell�vattablGty � � Northampton,-MA 01060 Two`Sets of Siructt€taE PEans` fr a El riN Northampton,, Gas 10 PO 413-587-1240 Fax 413-587-1272 Ptof/Stte PEans s Northampton,MA 01060►-'�� APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed>byoffice Map Lot Unit /`Y(y 7 YlCtl�tiC�J I Zone Overlay District Elm'St:District CB District SECTION 2-:PROPERTY OWNERSHIP/AUTHORIZED AGENT . 2.1 V Owner of Record: I O r � .,.. _ � ,mss _ .�..___.(� / ,.�___, Name(Print) Current Mailing Address: Signature Telephone 2.2 Authorized Agent: Name(Print) Current Mailing Address Signature Telephone h� 5 SECTION 3-:ESTIMATED.CON STRUCTION COSTS> . Item Estimated Cost(Dollars)to be Official Use.Only completed by ermit applicant 1. Building Building Permit Fee 2. Electrical J�� (b)Estimated Total Cost of Construction from 6 3. Plumbing i Building Permit°Fee 4. Mechanical(HVAC) 5. Fire Protection _...._... 6. Total=0 +2+3+4+5) Check Number This Section For'Official Use Only,' Building Permit Number Date :Issued Si nature: Building Commissioner/Inspector_of Buildings Date File#BP-2015-0857 APPLICANT/CONTACT PERSON KRIS THOMSON ADDRESS/PHONE 362 KENNEDY RD LEEDS01053 (413)549-1027 Q PROPERTY LOCATION 58 BRIDGE ST MAP 32A PARCEL 260 001 ZONE URC(100) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled out Fee Paid Tvpeof Construction:_REPAIR POST BASE AND SUPPORT BATH FLOOR New Construction Non Structural interior renovations Addition to Existin Accesso Structure Building Plans Included: Owner/Statement or License 084152 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: pproved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management D Dela Signature of Buildin Offic al Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. 58 BRIDGE ST BP-2015-0857 GIs#: COMMONWEALTH OF MASSACHUSETTS MV.-Block: 32A-260 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2015-0857 Proiect# JS-2015-001673 Est. Cost: $2300.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KRIS THOMSON 084152 Lot Size(sq. ft.): 21344.40 Owner: NORTHAMPTON HISTORICAL SOCIETY Zoning. URC(100)/ Applicant: KRIS THOMSON AT: 58 BRIDGE ST Applicant Address: Phone: Insurance: 362 KENNEDY RD (413) 549-1027 (� LEEDSMA01053 ISSUED ON.•3 11 7/2015 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR POST BASE AND SUPPORT BATH FLOOR POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeTylae: Date Paid: Amount: Building 3/17/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner